early identification of neurological abnormalities in the nicu infant max wiznitzer, m.d. division...
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Early Identification of Neurological Abnormalities in the NICU Infant
Max Wiznitzer, M.D.
Division of Pediatric NeurologyRainbow Babies and Children’s HospitalCleveland, Ohio
Common Problems in the NICU
PrematurityIVH=Intraventricular HemorrhagePVL=Perventricular Leukomalacia
Neonatal encephalopathyHypoxic-IschemicInfarction
Seizures
Intraventricular Hemorrhage
CausationPretermTerm
PresentationCatastrophic- Fortunately rareSaltatory-More common; stuttering evolution Silent-Most common
Grading severity
*GRADING OF IVH (per J. Volpe):
-Grade I: Bleeding confined to periventricular area (germinal matrix)
-Grade II: Intraventricular bleeding (10-50% of ventricular area on sagittal view)
-Grade III: Intraventricular bleeding (>50% of ventricular area or distends ventricle)
-Intra-parenchymal echodensity (IPE) represents periventricular hemorrhagic infarction and is often referred to as Grade IV IVH.
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*OUTCOME and PROGNOSIS:
Progressive Ventricular Neurological
Severity of IVH Mortality (%) Dilatation (%) Sequelae (%)
Grade I 5 5 5
Grade II 10 20 15
Grade III 20 55 35
IPE 50 80 90
(In general, outcomes with IVH Grade I or II are similar to infants without IVH.)
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*Clinical FeaturesCatastrophic Syndrome
Evolves in minutes to hoursDeep stupor or comaRespiratory arrhythmia, hypoventilation, apneaGeneralized tonic seizures, “Decerebrate” posturingEyes- Pupils fixed, no Doll’s eyeFlaccid quadriparesis
*Clinical FeaturesCatastrophic Syndrome (cont.)
Falling Hematocrit
Bulging Anterior Fontanelle
Hypotension, Bradycardia
Temperature derangements
Metabolic acidosis, DIC, Jaundice
Abnormalities of glucose and water homeostasis (Hyperglycemia, SIADH)
*Clinical Features
Saltatory syndromeStuttering evolution : hours to dayAltered level of consciousnessAltered motility (usually decreased )HypotoniaAbnormally tight popliteal angle (84% if IVH, 10% if no IVH)Abnormal eye position / movementRespiratory disturbance
*Clinical Features
Clinically silent syndrome:Careful, serial clinical assessments will miss 25-50% of infants with IVHMost valuable sign is unexplained fall of Hematocrit or failure of Hematocrit to rise after a transfusionMore common with smaller bleeds
(with associated better prognosis )
Intraventricular Hemorrhage
ConsequencesHydrocephalusGerminal matrix damageHemorrhagic infarction
AssessmentUltrasoundMRIEvoked potentials
Neonatal EncephalopathyPeriventricular LeukomalaciaHypoxic-ischemic encephalopathy
Near total/profound asphyxiaProlonged partial asphyxia
Infarction (stroke)ArterialVenous
Hypoxic-ischemia Encephalopathy
DiagnosisClinical evolution
Impact and timing of cell deathNecrosisApoptosis
Radiologic assessmentUltrasoundCT scanMRI
Use of EEG
Use of Technology for Early Identification of ProblemsMRIEvoked potentialsEEGNear Infrared SpectroscopyExamination
Analysis of Angles (Amiel-Tison)Assessment of general movements (Prechtl)